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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701192
Report Date: 05/19/2023
Date Signed: 05/19/2023 04:05:19 PM


Document Has Been Signed on 05/19/2023 04:05 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:VITA BELLA ELDERLY CARE IIIFACILITY NUMBER:
342701192
ADMINISTRATOR:LABELLA, MARKFACILITY TYPE:
740
ADDRESS:6700 SUN RIVER DRTELEPHONE:
(916) 490-0237
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:14CENSUS: 6DATE:
05/19/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Kaydia Sharp & Mark Labella & Diana Garcia. TIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPAs) Pang Lee and Avelina Martinez arrived at the facility to conduct an unannounced post-licensing inspection on 05/19/2023 at 8:30 AM. LPA Lee met with care staff Kaydia Sharp and explained the purpose of the visit. Care staff Kaydia assisted with today’s visit.

LPAs inspected the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms, client bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. The facility has one public telephone in the common area. The facility has the required posters posted in the facility. This facility is a single story building licensed to serve four-teen (14) non-ambulatory residents. LPAs observed the facility to be free of odor and clean. LPAs observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPAs observed exposed wires near and on the fire place area. LPAs observed the emergency exit gate to be not in good repair. In addition, the emergency exit gate was locked. LPAs observed a big piece of glass against the emergency exit gate. LPAs observed two dead birds on the ground, which was located next to the residents' patio area. LPAs also observed screws on the outside fire pit, which is located in a designated resident area. LPAs also observed the fire pit not be in good, and some of the fire pit bricks were broken. LPAs observed a gutter cap was not properly installed, which is a tripping hazards to residents in care

Furthermore, during the pre-licenseeing process, the licensee agreed to installed an exterior vinyl hallway enclosure that would protect residents from the outside elements. Also, the Department received an email on January 2, 2023 from the Licensee confirming that a vinyl enclosure would be installed to fully cover the residents bathroom passage way to ensure residents are able to go to and from bedroom to bathroom number three. However, during today's visit LPAs observed the vinyl enclosure was taken down, and parts of the vinyl enclosure were left on the ground causing a tripping hazard (Wood Boards). As a result, the Licensee is not following the plan of operation and the agreed upon terms. Continued LIC 809-C
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: VITA BELLA ELDERLY CARE III
FACILITY NUMBER: 342701192
VISIT DATE: 05/19/2023
NARRATIVE
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LPAs observed sufficient seven day non-perishable and two day perishable food supplies. The resident bathroom water temperature measured at 118.8 degrees Fahrenheit, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers, smoke and carbon monoxide detectors are in good repair. Fire extinguisher was last serviced on 09/21/2022. Facility thermostat observed at 72 degrees Fahrenheit. LPA Lee checked medication storage and found medication to be locked away and inaccessible to clients. LPA Lee reviewed 3 out of 6 medication administration record (MAR) and it was complete. First aid kit was checked and is complete. LPA Lee requested client and staff files for review. LPAs reviewed 3 out of 6 client files and 3 out of 3 staff files and they were not complete. LPAs reviewed staff criminal record clearances and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared; however it was learned that two out of three facility staff were not associated to the facility. Moreover, the facility staff 1, 2, and 3 files did not have training documentation. Staff 3 (S3) did not have LIC 501 Personnel Record or Application. Moreover, the facility did not maintain resident records. Resident 1 (R1) and resident 3 (R3) admission agreement Addendum contain inaccurate information. The addendum is for facility Abounding Love.

An immediate $500.00 civil penalty shall be assessed on May 19, 2023; based on observation: "Facility is not adhering to their approved fire clearance." Violation of California Code of Regulations Section 87203(a) was assessed on 05/19/2023 because the facility did not adhere to fire clearance and fire safety regulation.

An immediate $500.00 civil penalty shall be assessed on May 19, 2023; based on observation and review "Facility is not adhering to personnel requirements/background association of employees." Violation of California Code of Regulations Section 87411(g) was assessed on 05/19/2023 because the licensee did ensure that staff 2 and 3 were associated to the facility prior to working.

An exit interview was conducted, and a copy of the LIC 9099 report, LIC 9099-D, and appeal rights were given to the facility.


As a result of this post pre-licensing visit, the facility is not in compliance with Title 22 Regulations, and the deficiencies can be found on the LIC 809-D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 05/19/2023 04:05 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: VITA BELLA ELDERLY CARE III
FACILITY NUMBER: 342701192

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(c)(1)(A)
Personnel Records (c) Licensees shall maintain in the personnel records verification of required staff training and orientation.87412 Personnel Records (1) The following staff training and orientation shall be documented: (A) For staff who assist with personal activities of daily living, there shall be documentation of at least ten hours of initial training within the first four weeks of employment, and at least four hours of training annually thereafter in one or more of the content areas as specified in Section 87411(c)(2).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and file review staff 1 and staff 2 and staff 3 did not have any training documentation in their files. This posed a potential health and safety risk to residents in care.
POC Due Date: 06/02/2023
Plan of Correction
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Facility staff agrees to email training documentation to LPA Lee by POC date 06/02/2023 by 5PM. In addition, training documentations should be filed in the personnel files.
Type B
Section Cited
CCR
87506(a)
87506(a) Resident Records The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and file review, the Licensee did not ensure Admission Agreement Addendum had the correct facility name and information. This posed a potential health and safety risk to R1 and R3.
POC Due Date: 06/02/2023
Plan of Correction
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Facility Staff agrees to complete new admission agreements for R1 and R3 by POC date 06/02/2023 by 5 PM.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2023
LIC809 (FAS) - (06/04)
Page: 6 of 6


Document Has Been Signed on 05/19/2023 04:05 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: VITA BELLA ELDERLY CARE III
FACILITY NUMBER: 342701192

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(g)
Personnel Requirments (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on today's visit LPAs learned that staff 2 was not associated to facility, however, S2 was present during today's visit and were caring for residents. S3 is also not associated to the facility, however, S3 was not present at today's visit. This posed an immediate health and safety risk to residents in care
POC Due Date: 06/01/2023
Plan of Correction
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Facility staff will ensure staff 2 and 3 are associated to the facility by POC date 06/01/2023 by 5 PM.
Type A
Section Cited
CCR
87202
87202(a) Fire Clearance All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and facility inspection, the Licensee did not ensure the emergency fire exit door was kept unlock. This posed an immediate health and safety risk to residents in care
POC Due Date: 05/19/2023
Plan of Correction
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The facility staff unlocked the emergency exit door during the visit. Facility agrees to conduct a fire clearance training for all staff. Training documents should be emailed to LPA Lee by POC date 05/19/2023 by 5PM
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2023
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 05/19/2023 04:05 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: VITA BELLA ELDERLY CARE III
FACILITY NUMBER: 342701192

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(a)

87208 (a) Plan of Operation Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and facility inspection, LPAs observed Vinyl passage way enclosure was taken down. The Licensee did not ensure to follow the agreed upon plan of operation. This poses a potential health and safty risk to residents in care.
POC Due Date: 06/02/2023
Plan of Correction
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The facility agrees to repair and install enclosure passage way by POC date 06/02/2023. In addition, Licensee agrees to comply with plan of operation and provide a written statement that Licensee will review plan of operation regulations by POC date 06/02/2023. Statement should be emailed to LPA Lee by 06/02/2023 by 5pm.
Type B
Section Cited
CCR
87303

87303(a) Maintenance and Operation The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and facility inspection, LPAs observed broken glass, dead birds, nail screws, broken bricks, plugged sewer, exposed wires, hole on wall located at the kitchen exit door, exterior gate not in good repair, Gutter cap not installed properly, and wood board on ground. The licensee did not ensure facility was maintained in good repair. This posed a potential health and safety risk to residents in care.
POC Due Date: 06/02/2023
Plan of Correction
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Facility staff agrees to make all facility repairs by POC date 06/02/2023 by 5 PM. Staff agrees to call LPA Lee when repairs are completed on 06/02/23. POC will be cleared by visit.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2023
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 05/19/2023 04:05 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: VITA BELLA ELDERLY CARE III
FACILITY NUMBER: 342701192

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87405(d)(2)
87405(d) (2) Administrator - Qualifications and Duties The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply...knowledge of and ability to conform to the applicable laws, rules and regulations.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviews the Administrator did not follow plan of operations and did not conform to applicable laws, rules, and regulations. This posed a potential health and safety risk to residents in care.
POC Due Date: 06/02/2023
Plan of Correction
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The facility staff agrees to have the Administrator review Administrator - Qualifications and Duties regulations and write a statement that they have completed and understand the Administrator - Qualifications and Duties regulation by POC Date 06/02/2023.
Section Cited
Deficient Practice Statement
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2
3
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POC Due Date:
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2023
LIC809 (FAS) - (06/04)
Page: 4 of 6